J. Phys. Ther. Sci.

24: 671–674, 2012

The Effect of Core Stabilization Exercises Using a

Sling on Pain and Muscle Strength of Patients
with Chronic Low Back Pain

Young-Dae Yoo, PhD1), Yeon-Seop Lee, PT, MSc2)

1) Department of Physical Therapy, Cheongam College
2) Department of Physical Therapy, Daegu University Graduate School of Physical Therapy, Daegu
University: Naeri-ri, Jinlyang, Gyeongsan-si, Kyeongsangbuk-do, 15 Republic of Korea.
TEL: +82 51-624-0394, FAX: +82 51-624-1394, E-mail: bulchun325@naver.com

Abstract. [Purpose] This study examined the feasibility of using an intervention of core stabilization exercises
using a sling to control pain and muscle strength of patients with chronic low back pain. [Subjects] The subjects, 30
chronic low back patients, were divided randomly into two exercise groups: one group performed core stabilization
exercises using a sling (n=15), and the other group performed mat exercises group (n=15). Each exercise program
was performed three days per week for four weeks. Pain and muscle strength were measured before and after the
intervention. Pain was assessed using a visual analogue scale (VAS) and muscle strength was measured with a
Tergumed device. [Results] The differences in the VAS scores for the sling exercise and mat exercise program
were statistically significant between pre and post intervention in both groups. Muscle strength increases were also
statistically significant. However, the comparison of sling exercise and mat exercise program showed no statisti-
cally significant differences between the groups, post-intervention. [Conclusion] Both the sling exercise and the mat
exercise program reduced chronic low back pain improved patients’ lumbar muscle strength, and decreased VAS
scores; and the sling exercise was more effective than the mat exercise program. Further study is needed to develop
the sling exercise for effective use in clinical practice for the treatment of chronic low back pain.
Key words: Chronic low back pain, Core Stabilization Exercise, Sling exercise
(This article was submitted Dec. 26, 2011, and was accepted Mar. 4, 2012)

INTRODUCTION controlling spine segments and providing stability has been

Low back pain is typically alleviated through 1–2
months of continued and mostly conservative treatment
methods. However, some low back pain patients continue to
experience pain for more than 12 weeks. This type of pain is
categorized as chronic low back pain.
Over the course of their lives, 70–85% of people will
experience low back pain and over 80% will experience
recurrence of the pain1). Although 80–90% of patients
recover within 6 weeks2), a fraction (5–15%) do not recover
from the pain3). Due to the development of low back pain,
sufferer’s extent of activity is reduced in order to limit the
amount of pain, and this results in weakening of the back
muscles and functional decline4). The requirement for
long-term bed rest is the main reason for delayed treatment.
A greater recovery rate is therefore seen for proactive activ-
ities and exercise programs than for bed rest5). Proactive
activities and exercise programs reduce the amount of pain,
while improving physical strength and endurance; thereby
improving functional ability, reinforcing psychological
stability, and reducing stress and fatigue6, 7).
Strength training, flexibility improvement training,
and cardio-training are being researched as exercises to
reduce back pain8, 9). Recently, a core stability exercise for
used with a focus on treating instable spinal segments10).
The success of the core stability improvement exercise in
alleviation of chronic back pain and prevention of recur-
rence has also prompted the use of slings during exercises
for back pain.
The use of a sling in a core stability exercises allows
active participation by back pain patients in their treatment.
In particular, this treatment method may be used effectively
in an antigravity state, such as performing exercises in water,
and patients using this method may can begin to exercise
earlier. By reducing the amount of weight exerted by gravity,
the method may also contribute to stabilizing back pain. In
other words, this exercise method integrates the concept
of core stability exercise and the latest exercise treatment
theories as a new approach to exercise treatment11).
However, the effectiveness of the use of a sling for
chronic low back pain patients has not been sufficiently
studied, especially in comparison to the effectiveness of
the generally used mat exercises. Therefore, the aim of the
present study was to compare the sling and mat exercises
on pain and on the ability of extensor muscles in order to
ascertain the most effective exercise method for patients
with chronic low back pain.
672 J. Phys. Ther. Sci. Vol. 24, No. 8, 2012
Table 1. Characteristics of study participants
Sling Exercise Group (n=15)
Age (years) 20.1 ± 0.7
Height (cm) 168.2 ± 9.0
Weight (kg) 56.9 ± 14.3
(n=30) (mean ± SD)
SUBJECTS AND METHODS
Subjects
The study subjects were 30 university students of
C University located in S city, who were in their 20s,
complained of chronic low back pain, and who scored less
than 18 on Handler’s 10-minute long differential aptitude
test. None of the test subjects who agreed to participate
received any type of treatment during the test period and
none of them had motor paralysis or disabilities. Half (n=15)
of the students were randomly assigned to a sling exercise
group and the remaining 15 to a mat exercise group (Table
1).
A visual analogue scale (VAS), consisting of a 10 cm
rule without markings, was used to assess the test subjects’
subjective pain12). A Tergumed device (Proxomeds,
Germany) was used to measure extensor and stretching
strengths. This device reduces resistance at a certain
weight and provides a measure of the range of motion
(ROM) and power. The reliability levels of the ROM and
isometric strength measurement had ICCs of 0.81–0.8613).
The test subject’s thighs above the knee were set parallel
and the pelvis was completely fixed to the pelvis fixation
plate using hip and thigh restraints. Measurement was done
by pushing the plate while applying force to the back pad
for 2 to 3 seconds. When the highest point was reached,
the test subject was told to maintain maximum contraction
for 1 to 2 seconds. This was measured 3 times and the test
subjects were allowed 30 seconds of rest in between the
measurement14).
Handler’s 10-minute long differential aptitude test was
used to select chronic low back pain patients15). It is a
15-item survey developed to measure alleviated or aggra-
vated pain concerning low back pain patients’ functional
differences. The patient indicates his or her own reactions.
Considering the test subjects’ young age, Item 10 regarding
sexual intercourse was excluded from the survey. In general,
patients who score 18 or less are considered chronic back
pain patients. Back pain complaints by patients with scores
less than 14 are more objectively categorized16).
Methods
The two exercise programs, consisting of sling or mat
exercises, were conducted three times a week for four weeks.
The sling exercise program was part of a core stability
exercise that consisted of 6 movements: body stretch,
standing, pushing the upper body while seated, strength-
ening abdomen while standing, lying on the front, and lying
Mat Exercise Group (n=15)
20.5 ± 0.5
164.5 ± 4.6
54.7 ± 7.6
on the back. Each action was maintained for 20 seconds
followed by a 10-second rest. Each action was performed 6
times for one set and repeated in three sets, with a 90-second
rest between sets. In the event of pain or muscle paralysis,
exercise was suspended. Each action was orally described
to the patient.
The mat exercises consisted of a preparatory exercise,
belly blaster, cobra, butterfly, 3-stage pelvis stability
exercise, hamstring stretch, folding knees to the chest,
twisting the spine while lying down, abdominal breathing,
cross extension, cobra, and a final abdominal breathing. Each
action was maintained for 10 seconds (except for abdominal
breathing, which was maintained for 20 seconds on the right
side and 20 seconds on the left side), with a 10-second rest
between actions. Each action was conducted twice in a set
and repeated for a total of two sets, with a 15-second rest
between sets. In the event of pain or muscle paralysis, the
exercise was suspended. Each action was orally described
to the patient.
Data were statistically analyzed using Windows SPSS
Version 12.0 Program. All the data using the Kolmogorov-
Smirnov test result verifying the normality and parametric
test was used for the normal distribution. Changes before
and after exercise were compared using the paired t-test.
Changes between the two groups were compared using the
independent t-test. Statistical significance was accepted at
values of α<0.05.
RESULTS
Subject’s general characteristics before conducting the
exercise programs showed no statistically significant differ-
ences in terms of pain between the sling exercise group
and the mat exercise group. The sling exercise group and
the mat exercise group showed significant improvements in
pain after the exercise intervention (p<0.05). However, no
statistically significant difference was seen in the degree of
pain between the two groups (p<0.05) (Table 2).
The body extensor muscle strength test before exercise
showed no statistically significant difference between the
sling exercise group and the mat exercise group and both
groups showed significant improvements after the exercise
intervention (p<0.05). A comparison of the degree of change
in extensor muscle strength after the exercise intervention
showed no statistically significant difference between the
two groups (p<0.05) (Table 3).
DISCUSSION
Regular exercise by chronic back pain patients has the
 673

Table 2. Comparison of vas data between the sling and mat exercise groups

VAS Data Sling Exercise Group (n=15) Mat Exercise Group (n=15)
Pre-intervention 4.5 ± 0.5 4.6 ± 0.5
Post-intervention 1.3 ± 0.5* 1.8 ± 0.6*
Change in VAS 3.2 ± 0.6 2.8 ± 0.8
(mean ± SD) (unit: cm) Value are Mean ± SD; *= p<0.05.

Table 3. Comparison of trunk extensor strength between the sling and mat exercise groups

Trunk Extension Power Data Sling Exercise Group (n=15) Mat Exercise Group (n=15)
Pre-intervention 408.4 ± 241.6 371.1 ± 77.6
Post-intervention 685.1 ± 350.2* 506.3 ± 88.6*
Change in Trunk
276.7 ± 171.4† 135.2 ± 0.61.1
Extensor Strength
(mean ± SD) (unit: N) *: Paired t-test value, †: independent t-test value, ; *= p<0.05, †= p<0.05.

following effects: reduced pain, improved muscle strength,
increased stability and coordination, improved quality of
life, better body stability and function, and positive psycho-
logical aspects. Exercises for low back pain include those
aimed at improving muscle strength, flexibility, and cardio-
vascular function. Current research is now focusing on the
effect of core stabilization exercises on the alleviation of low
back pain.
In the present study, we found that core stabilization
exercises using a sling system affected subjective pain when
compared with mat exercises. However, a comparison of the
degree of change after the exercise intervention indicated no
significant statistical difference between the groups. This
result contradicts that of Park Hye-sang17), who found a
significant difference in pain improvement between a group
that used a core stabilization exercise using a ring and a
group that did not; Unsgaard-Tondel et al.18) and by Pereira
et al.19) also reported significant differences. On the other
hand, Nam Hyeong-chun20) compared pain indexes using
Handler’s 10-minute long differential aptitude test between a
sling exercise group and a ring exercise group, but found no
significant between group difference in the post-intervention
changes, as in the present study.
A core stability exercise is conducted within a range
free from pain by adopting isometric stabilization exercises
that control unstable posture and that provide lower lumbar
postural control for functional activities. The purpose
of treatment is to reduce the maximum amount of stress
physically applied to the spinal structure while the patient
executes optimal functions and to develop and improve
muscles including the erector spinae, multifidus, quadrates
lumborum, and musculi abdominis. All of these muscles
help to maintain adequate neurological muscle control and
coordination and are involved in the stabilization of the lower
lumbar area21). Core stabilization exercises allow recovery
of the function of local muscles and the latissimus dorsi,
thereby contributing to improvement in body posture. Pain is
reduced by decreasing the transmission of pain stimuli from
the ligaments and articular capsules to the spine.
Extensor muscle strength in the sling and mat exercise
groups showed significant differences after exercise inter-
vention in both groups. The statistically significant difference
seen between the two groups indicates that the sling core
stabilization exercise does improve muscle activity, as
confirmed by studies based on using ultrasonic images22),
while reducing pain, increasing the range of activity, and
improving quality of life and functional capacity18). Women
who complained of low back pain and pelvis pain after
giving birth also responded positively to core stabilization
exercise and showed a decrease in pain and increased quality
of life and functional capacity23).
Nam Hyeong-chun20), used electromyography to
compare a sling exercise with a mat exercise, and found
a significant increase in muscle activity in the obliquus
externus and erector spinae muscles after the exercise for the
sling group but not for the mat group. Neither group showed
a significant difference in terms of exercise-related muscle
strength change. These results differ from those of the mat
exercise group in the present study, in which a significant
change was seen in the strength of the extensor muscle. This
suggests that the exercise program used in this study may
lead to greater strength improvement than the programs
used in previous studies. A previous study comparing bodily
coordination after conducting a sling exercise and a mat
exercise for 4 weeks also showed a significant increase in
muscle strength in both groups24).
The results of the present study indicate that core stabili-
zation exercises are effective at reducing pain and improving
extensor muscle when used as sling or mat exercise, and are
successful at reducing pain and improving muscle strength.
In particular, extensor muscle strength showed a significant
increase after both sling exercise and mat exercise. A sling is
a good tool to use in an exercise program that is focused on
increasing extensor muscle strength for those who have diffi-
culty moving on the mat and maintaining position. In places
where use of a sling is difficult, the sling may be replaced by
a mat. Subsequent studies should focus on alleviation of pain
and improvement of quality of life and functional capacity,
before focusing on muscle strength.
674 J. Phys. Ther. Sci. Vol. 24, No. 8, 2012
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